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The interim investigation report was published in early April
THE head of the Pseudonomas review team has been asked to address serious concerns raised by the family of the third baby to die from the infection in Belfast’s Royal Jubilee Hospital.
Belfast solicitor Ernie Waterworth has written to Professor Pat Troop – who is heading up the review team – requesting that she ensures issues are addressed by the Belfast Health Trust in relation to gaps in information provided to the family about their baby’s care.
Speaking to The Detail earlier this month, Mr Waterworth revealed that the family had questions about missing hospital records from January 14. Despite assurances following a meeting with the Health Minister, the family claim theiir concerns have still not been addressed by the Belfast Trust.
A report of an RQIA-led investigation into the pseudomonas outbreak was published at the start of this month. The final report is due to be published at the end of May.
Mr Waterworth believes many questions remain unanswered for the family of ‘Baby 3’.
OUTSTANDING ISSUESSpeaking at a meeting of Stormont’s Health Committee on April 4 this year, Professor Troop told members that following the outbreak she was not aware of any unit in the UK that does not now use sterile water. She also confirmed that they were continuing tests around the unit’s taps and their design.
Mr Waterworth believes the initial report has left many issues still outstanding.
He said: “I understand that many lessons will have to be learnt following these tragic events. For the family of ‘Baby 3’ and each of the other families however, it’s too late.
“Unfortunately, I don’t believe that the interim report has got to the heart of why many of the mistakes occurred and particularly why any oversights were allowed to happen.”
In the interim report the review team reported that the taps and sinks in the Royal Jubilee and Craigavon neonatal units had been recently replaced prior to the outbreak and that the taps and sinks in Altnagelvin Hospital’s neonatal unit had been in use since the unit opened in February 2009.
Sensor taps, which do not require the operator to touch the tap, had been installed in all three units.
The report makes reference to the potential links between sensor taps and pseudomonas infection.
It states: “There has been considerable debate regarding which design of tap is most likely to protect the water system from bacterial contamination. In many healthcare settings, sensor taps have been introduced as the no-touch operation reduces the risk of spread of infection through touching tap surfaces.
“However, sensor taps have internal components which may support pseudomonas growth if they contain carbon. Also, there has been concern that low flow rates increase the risk of the growth of Pseudomonas.”
However, despite this, the report also states that Royal Jubilee had recently installed sensor taps following the latest outbreak.
From January 20 to February 6 this year the intensive care unit at the Royal Jubilee was refurbished, with central panels, new sinks and ultra violet (UV) sensor taps fitted. On February 8 rooms 5a, 5b and 5c had new panels, new sinks and sensor taps installed.
Bacteriologist Professor Hugh Pennington believes there is still confusion around the use of these taps and what the report is actually saying.
He said: “As far as I can tell by the Troop Report, the fundamental issue revolves around the type of taps being used, although I think the Troop report itself is a bit guarded about this.
“It is essentially pointing to the fact that maybe these automatic taps, the UV taps, have got a design problem that helps the bug to grow around the valves and washers inside the tap and I think that’s taken people by surprise. But if such taps have been installed as recently as February, there is serious oversight here.”
Following the publication of the report in early April, some members of the independent review team gave evidence to the Health Committee.
Speaking at the meeting on the April 4, Dr David Stewart outlined his concerns about the sensor taps.
He said: “Sensor taps were put in because it seemed to be a very good idea that a tap would not be touched and, therefore, from a hand-hygiene perspective, one is not touching the surface and spreading an organism through that method.
“Those taps were put in on a widespread basis for what seemed an obvious reason — to reduce the risk of spreading infection through touching taps. In each of the three units in which there has been an outbreak or cluster, those taps were put in within the past three years. Before that, we understand that the taps would have been the more traditional lever type.”
GAME CHANGERSpeaking at the same health committee meeting, Health Minister Edwin Poots told members that professor Troop had described the introduction of sterile water as a “game changer”. However, many questions still remain around why it took so long to implement such changes, particularly at the Royal Jubilee.
The Troop review team found that in the five neonatal units in Northern Ireland it was normal practice to use tap water for nappy changes. This has also been common practice in other parts of the United Kingdom.
In units using tap water, a small container of tap water was taken from hand washing stations. The review team consider that this was a likely route for transmission of Pseudomonas from taps to babies.
In Altnagelvin Hospital, following the death of the first baby on December 10, the Altnagelvin Infection and Prevention Control (IPC) team informed the Western Trust Medical Director about the cases of infection with pseudomonas and a terminal clean)of the ICU room took place while parents were informed.
By December 13 action was issued so that sterile water would be used at all times for all babies in ICU and High Dependency Unit (HDU) and that no water was to be used from the taps in the ICU.
By December 22 guidance was issued by the Department advising of the risk from water sources. It also stated the actions that were required and the importance of good infection prevention and control in organisations.
However, at the Royal Jubilee it wasn’t until January 17 at an incident meeting where a Pseudomonas outbreak was officially confirmed that the issue of sterile water was even considered.
Initial control measures were then established which included: restricting admissions to NICU; environmental sampling to include potential habitats of Pseudomonas (especially taps and water); with particular reference to the use of sterile water for nappy changes.
This directive wasn’t rolled out across the entire HSC trusts until January 21, at the time the Health Minister said that the practice had been established in Londonderry and Belfast at this time.
Despite this, the Troop report has already established that the use of sterile water in the neonatal wards was not being widely practised.
The policy in relation to infant hygiene in the Royal Jubilee’s maternity ward was developed in 2002. It outlines a number of measures that should be put in place when assessing and attending to infant hygiene needs. This included the use of sterile water at all times and it makes reference to using a “bowl of warm water” within the ward.
However following guidance, the policy was updated in March 2012 and while sterile water is still listed as a requirement, the use of a “bowl of warm” water is no longer advised. It also includes specific details on the importance of maintaining the integrity of the skin when preventing infection as it “serves as a barrier against infection.”
Mr Waterworth believes all of the families involved deserve the truth.
He said: “All of the issues that have been identified as outstanding from the interim report are directly relevant to my clients’ case and the expectation is that they will be completely addressed in the second part of this report.
“In relation to concerns around the medical records of ‘Baby 3’, the Minister is aware of our issues, the trust is aware of these issues and now professor Troop will be made aware of them directly.”